SSI prevention is central to all HCAI reduction strategies in surgical patients: A holistic view
There was so much excitement last week as global infection prevention practitioners celebrated international infection prevention week (IIPW). Most teams and societies showcased their teams and the important work they do to prevent avoidable Healthcare Acquired Infections (HCAI). I even participated in a Tweet chat that was hosted by APIC. I thoroughly enjoyed this, reminding of days before Covid when I used to join so many Tweet chats (Good old days 😊). In the UK, it was super inspirational to see so many tweets from my #IPCFamily. I thoroughly enjoyed Jon Otter’s latest blog which he did as part of IIPW. In this blog, he focused on his recent talk at Guy’s & St Thomas’ NHS Trust annual IPC conference. He presented what he felt should be IPC priorities for the next 3 - 5 years in the following priority order: antimicrobial stewardship, embedding digital systems to enhance our clinical services, preventing Gram-negative bloodstream infection, preventing SSIs, preventing the transmission of SARS-CoV-2 in our hospitals. SSI is not ranked that highly which may suggest that lots of work is still required to raise awareness of this important patient safety initiative. As highlighted in my last blog, the pendulum is shifting, there’s lots of interest now in SSI surveillance and prevention.
A holistic view
So, what’s your IPC priorities for the next 5 years? For me I decided to focus on SSI surveillance and prevention as I have always done in recent years. I am aware that I have covered other IPC aspects of a surgical patient directly or indirectly as well over the years. Here’s why…
Let’s think of a surgical patient who comes into hospital, has cardiac surgery, and then develops a deep or organ/space infection e.g., mediastinitis. This patient is likely to suffer significantly from their infection, i.e., may:
return to the operating room for a washout and debridement of wound and possibly end up with negative pressure therapy dressings to manage the infection
end up in a critical care unit, ventilated which increases their risk of developing Hospital Acquired Pneumonia (HAP)
require a urinary catheter especially if they become too unwell
need intravenous antibiotics to manage their infection
By looking at the above example you can begin to see how linked all branches of infection prevention and control are, which means we must always adopt a holistic approach when managing any patient that comes into healthcare. I decided to look at the different possible infections the above surgical patient may develop.
1. This patient may require input from intravenous access device (IVAD) practitioners if they become too unwell and require IVAD for intravenous (IV) fluids or drugs. IVAD teams support management of ongoing IV-line care. Garlot et al (2014) suggest that most Catheter Related Blood Stream Infections (CRBSI) are associated with Central Venous Catheters (CVC). According to this paper, the relative risk for CRBSI is up to 64 times greater with CVCs than with peripheral venous catheters which is astounding! Therefore, any SSIs that lead to insertion of peripheral or worse still CVC must be avoided at all costs. If infections are unavoidable, good line care is a must.
2. A microbiologist or Infectious Diseases (ID) Physician must be consulted to advise on best antibiotic therapy to manage surgical site infections. Depending on the micro-organism implicated, giving additional doses of antibiotics is likely to drive up antimicrobial resistance. Given that the whole world including the UK is now fighting hard to preserve the antibiotics we currently have at our disposal, any additional antibiotic doses must be avoided whenever possible. When SSI is avoided, that need for an additional dose of antibiotics is also eliminated thus supporting the global antimicrobial resistance agenda. Furthermore, antimicrobial stewardship programs must be prioritized in all settings.
3. If a patient with a surgical site infection ends up on a breathing machine or ventilator in intensive care, depending on standards of mouthcare and other factors, the risk of Hospital Acquired Pneumonia (HAP) increases. In past point prevalence surveys (PPS), HAP is thought to be the most common HCAI therefore morbidity and mortality associated with this infection can’t be ignored. Again, reducing the incidence of avoidable SSIs will have positive benefits for patients through avoidance of these other infections.
4. Ventilated SSI patients lose their ability to control bladder function and most of these patients end up with urinary catheters, not just to prevent patients being constantly moist which increases the risk of pressure sores but also to monitor their renal function. An unintended consequence for these patients is the development of Catheter Associated Urinary Tract Infection (CAUTI). Although The ‘No catheter – No catheter associated urinary tract infection’ programme, a case study by Jackie Rees – a Nurse Consultant from Newcastle upon Tyne NHS Hospital Foundation are useful examples of reducing CAUTI incidence; for a very sick SSI patient avoidance of a urinary catheter may prove difficult. It is still acknowledged though that a Trust-wide Catheter Care group would still be useful to ensure appropriate management and removal as soon as possible. As they say, prevention is always better than cure, preventing avoidable SSIs removes the need to even contemplate urinary catheter insertion and associated risks.
5. It is clear from the above points (1-4), that when a patient develops a surgical site infection, the risk of other HCAI also increases which means increased antibiotic usage which in turn increases the risk of antimicrobial resistance. According to NHS England data, urinary tract infections (UTI) and CAUTI are thought to be a leading cause of E. coli and Gram-negative bloodstream infection, therefore their prevention is of paramount importance. Part of NHS England/Improvement’s ambition to reduce Gram Negative Blood Steam Infection (#GNBSI) as part of initiatives to address antimicrobial resistance is centred around CAUTI reduction but again reducing avoidable SSIs could even make this work more manageable.
6. In relation to the current Covid pandemic, the last thing you want is for a surgical patient to be readmitted to healthcare or outpatient facilities with a surgical site infection which may increase their risk of Covid exposure and other avoidable nosocomial infections.
7. Another big topic beyond the scope of this blog is sepsis. There is already a lot of work going on to promote early sepsis identification and management to reduce the risk of death via #THINKSEPSIS campaigns. Again, as with any infection, as part of the sepsis management protocol, most patients receive broad spectrum antibiotics which increase risk of antimicrobial resistance. Avoiding SSIs could reduce risk of sepsis from SSI, CAUTI, HAP, GNBSI. You can already see what this blog is trying to highlight here.
Prevent One SSI, prevent collateral damage!
By avoiding surgical site infections, other types of infections (CAUTI, CRBSI, GNBSI, HAP, and sepsis can be avoided also which in turn reduce antibiotic use and consequently antimicrobial resistance. We need good surveillance data for the above infections to drive improvement which makes embedding of digital systems to improve clinical services an urgent priority. I have to say I was rather disappointed when I saw #TeamGSTT conference attendees rating SSI as a least priority within the next 3-5 years when in fact it should be integral to all efforts to reduce HCAI in surgical patients. Thus, going back to Jon’s priorities for the next 3-5 years, I think everything should be equally rated in my opinion. Given Covid and the increases in telemedicine or virtual assessments, digital revolution should already be part of our efforts to enhance our IPC surveillance systems so we can generate data that we can effectively use to inform and improve clinical practice. I did a poster for the Infection Prevention Society (IPS) conference a couple of years ago on the importance of embracing IT technology to improve patient safety and experience. Since then, in my current organization we managed to revolutionize the way surgical wound documentation is done which has improved how we collect objective surgical wound assessment data. I look forward to seeing many organizations following our example which has led to overall patient benefits.
Let’s not divide our patients into various sections, lets look at all infection control aspects holistically and work together to drive improvement. International Infection Prevention Week has come and gone but let’s all continue to do the best that we can for our patients throughout the year. Most importantly, let’s not forget the unprecedented pressures on all our staff during this pandemic. Most of our staff are tired and require ongoing support, love, kindness, and compassion so they continue to be motivated to do the best they can.
I conclude by saying that SSI prevention is as important as all the other IPC branches, so don’t leave it behind.